Provider Demographics
NPI:1730540303
Name:PETERS, AMANDA MARIE (COTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:PETERS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 SUNNY VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-6627
Mailing Address - Country:US
Mailing Address - Phone:573-429-8203
Mailing Address - Fax:
Practice Address - Street 1:2319 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4415
Practice Address - Country:US
Practice Address - Phone:870-919-0274
Practice Address - Fax:870-277-4335
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A985224Z00000X
MO2015002804224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant